Speed Bumps on the Way to an A.D.H.D. Diagnosis

WHEN Liz Goldberg, 53, was growing up, she always felt “a little off.” She received good grades and even completed a master’s degree in health administration, but it was always a struggle.

In school, she would procrastinate and then pull desperate all-nighters to study for an exam. She’d become hyperfocused on a project and let everything else fall by the wayside. Maintaining relationships was tricky. “I would concentrate intensely on a friend and then move on,” she said. She commuted to college one year simply because she had missed the deadline to apply for housing.

“I managed to achieve a lot, but it was difficult,” said Ms. Goldberg, a mother of three who lives near Philadelphia. “I sensed something was wrong, but others would always talk me out of it.”

Finally, in her late 40s, Ms. Goldberg was given a diagnosis of attention deficit hyperactivity disorder, a condition caused by signaling problems in the brain. The primary symptoms are impulsiveness, inattention, restlessness and poor self-regulation. Children with the condition tend to be hyperactive, but adults who have it often just seem distracted and disorganized.

Undiagnosed, A.D.H.D. can wreak havoc on relationships, finances and one’s self-esteem. Adults with the disorder are twice as likely as those without it to be divorced, for instance, and four times as likely to have car accidents. It’s no surprise that they also tend to have poor credit ratings.

“A.D.H.D. is a very debilitating mental disorder,” said Russell Barkley, a clinical professor of psychiatry at the Medical University of South Carolina. “It can produce more severe impairment, and in more domains of life, than depression or anxiety.”

More than 5 percent of adults have A.D.H.D., according to a recent study by Dr. Barkley. But just 10 percent of those adults have a formal diagnosis.

It’s an expensive problem for many consumers. Adults with the condition, particularly women, are frequently given a diagnosis of depression, anxiety or bipolar disorder instead — or their symptoms are dismissed, as Ms. Goldberg’s were.

Ms. Goldberg said of her eventual diagnosis: “It was so freeing. I realized, ‘I’m not stupid — I have a mental disorder.’ ”

Just getting the correct diagnosis can be costly. “Many clinicians do not know how to spot the signs,” said Ari Tuckman, a psychologist in West Chester, Pa., and author of a book about A.D.H.D., “More Attention, Less Deficit” (Specialty Press, 2009).

Clinicians may arrive at the diagnosis with a snap judgment, or they may send patients for lengthy and expensive neuropsychological evaluations. Both approaches tend to miss the main symptoms — and therefore waste the patient’s time and money.

If you think that you may have A.D.H.D., or that a friend or family member may, the first thing to do is get a proper diagnosis. Here’s how to get tested and what to avoid.

If you’re not quite sure if you or a family member has the disorder, start by printing out the Adult A.D.H.D. Self-Report Scale and answering the 18-question assessment. It was developed by a team of psychiatrists in conjunction with the World Health Organization, and it is used by many clinicians to diagnose A.D.H.D.

The test is simple and has a straightforward scoring system. Use the results only as a guide to gauge your symptoms or a family member’s; it should not serve as a final diagnosis.

Bear in mind that A.D.H.D. is not something you suddenly develop as an adult; you are born with it. “If you tell me, ‘My life was fine until I was 24,’ you don’t have this disorder,” said Dr. Barkley.

Avoid: Snap diagnoses.

Diagnosing this disorder takes time. A quick assessment, even by your favorite doctor or therapist, can miss important signs.

Photo

Ari Tuckman, a psychologist based in West Chester, Pa., says many doctors are not familiar with the signs of attention deficit hyperactivity disorder, and fail to make an accurate diagnosis.Credit
Laura Pedrick for The New York Times

“I can’t guess how many clients I have had who have seen other psychologists, psychiatrists and primary care physicians who missed their A.D.H.D., even though it was burning like a bonfire,” said Dr. Tuckman. “It’s possible to make a diagnosis by using a rating scale and a 10-minute discussion, but it’s also far too easy to make an inaccurate diagnosis or miss a diagnosis.”

Step 2: Find an experienced clinician.

Cost: $200 to $500.

Make an appointment, or more than one, with a psychiatrist, psychologist or neurologist who has expertise in diagnosing A.D.H.D. Ask your doctor or a psychotherapist for a recommendation, or contact a local chapter of the organization Children and Adults With Attention Deficit/Hyperactivity Disorder (informally known as Chadd) and inquire about local professionals.

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Dr. Barkley also suggests calling a nearby medical school or university psychiatry program and asking whether there is a doctor on staff who specializes in adult A.D.H.D.

An experienced clinician will typically schedule a two- to three-hour interview in one long visit, or two or three shorter ones. The clinician will ask about your history — how you performed in school as a child, how you got along with family members and friends.

The clinician also will ask about your present life — your job, your relationships, your driving record and your finances. He or she will also want to know if other members of your immediate family have an A.D.H.D. diagnosis.

To be found to have A.D.H.D., you must have specific symptoms that interfere with a significant part of your life, like your job or your marriage.

“Everyone has some of these symptoms,” said Dr. Tuckman. “But the person with A.D.H.D. has had them his entire life, and they are chronic and pervasive.” You can find the detailed diagnostic criteria on the Chadd Web site.

The clinician will most likely want to corroborate what you say with a family member. Some clinicians ask that a family member come to the interview, or fill out a questionnaire about your behavior and habits. “People with A.D.H.D. tend to underreport their symptoms,” said Dr. Barkley.

Avoid: An expensive neuropsychological evaluation.

You don’t need a costly and time-consuming neuropsychological evaluation — a series of tests that evaluate cognitive, behavioral and executive functioning and language skills.

“These tests were not designed to pick up A.D.H.D. deficits and are not sensitive enough,” said Dr. Tuckman. “It’s also overkill. It takes far longer and costs far more, $2,000 to $5,000, than is necessary.”

“Overtesting is a real problem” for patients seeking A.D.H.D. diagnoses, added Dr. Barkley. Not only are so-called neuropsychological tests inaccurate when it comes to A.D.H.D., but some unscrupulous providers may push them to reap bigger reimbursements from insurers.

A neuropsychological evaluation is useful, however, if you suspect you have learning disabilities or need accommodations in school or on tests.

Step 3: Understand your diagnosis.

Cost: $50 or so for some helpful books.

If you are given a diagnosis of A.D.H.D., study up on the disorder. Several helpful books are available, including Dr. Barkley’s “Taking Charge of Adult A.D.H.D.” (Guilford, 2010) and “Understanding Girls with AD/HD” (Advantage, 1999), by Kathleen Nadeau, Ellen Littman and Patricia Quinn, which Ms. Goldberg recommends.

Cognitive behavioral therapy often is helpful for people with A.D.H.D. A new book, “Cognitive-Behavioral Therapy for Adult A.D.H.D.” (Guilford, 2011), by Mary V. Solanto, just came out on this topic, and it describes strategies that may help people with the condition become more effective at everyday tasks.

Your clinician will probably suggest that you try medication as well as behavior therapy.

“Most people feel a tremendous sense of relief when they are diagnosed,” said Dr. Tuckman. “They realize, ‘My future doesn’t have to look like my past.’ ”

A version of this article appears in print on May 14, 2011, on Page B5 of the New York edition with the headline: Speed Bumps on the Way To an A.D.H.D. Diagnosis. Order Reprints|Today's Paper|Subscribe